What I like about it is the surgeon himself describes what happened. He details everything else he was doing that day, what he was thinking and how he might have been distracted. I was surprised by how transparent he was- most reports about wrong site surgery protect the identity of the doctor and leave out even the sex of the patient.

You could really picture what went on that day and what the real human consequences were of his mistake. After the surgery, the patient lost faith in the doctor and never came back. It’s these personal touches that really illustrate the problem with these mistakes and perhaps why and how they happen.

The article concludes-

In 1852, the Massachusetts General Hospital was featured in a New York Times article detailing a series of events that led to the death of a young patient. Under the care of the surgeon, Dr. John Collins Warren, the patient had received chloroform instead of the usual chloric ether anesthesia.

The event that we describe here, more than 150 years later, is a sad reminder that despite expert and well-intentioned providers, our patients continue to face risks caused by human fallibility and systems that do not fully support our efforts to provide safe care.

By publishing this case, we hope to encourage health care practitioners to discuss such events, investigate them fully, disclose them quickly and clearly to patients and their families, care for the providers involved, and use these learning opportunities to reduce the risk for future patients.

Let’s hope this transparency continues and it’s followed by real improvements in preventing medical errors.

Thanks for following the blog and highlighting Dr. Ring’s last thoughts. It’s easy to consider check lists and protocols a waste of time or a form of busy work. These stories reminds us why such safeguards are important.